To: Christine Parks
RARC
From: [REDACTED]
RE: Protocol G00146
Date: July 1, 2003
[REDACTED] and [REDACTED] cross-compared the protocols (see below) and records obtained from all possible sources (e.g., colony records, laboratory note books, check sheets) and compiled a list of discrepancies between approved protocols and actual records. The apparent and potential violations are summarized below. The period of this investigation is from March 2000 to present. The tabulated information in detail is available upon request.
Protocol approval date: 3/13/00 with final amendment on 4/19/00
Major amendment approval date: 10/15/01
Minor amendment date: 05/20/02
Renewal approval date: 04/14/03
1. Apparent Violations
- Bret left animals during the push-pull-perfusion (PPP) experiment for lunch 4 times. The protocol states that animals will be attended continuously. One animal died in the chair while Bret was at lunch.
- In 24 PPP experiments in 11 animals, 4 different drug challenges were given. The 3/13/00 protocol did not contain this, but in the 10/15/01 protocol the maximum number of drug challenges was added to be three.
- Five drugs (the ATP sensitive potassium channel blockers, tolbutamide and glybenclamide; the purinergic receptor blockers, PPADS and suramin; and the ATP hydrolysor, apyrase) that had not been stated in the 10/15/01 protocol were examined with PPP experiments.
- In 15 PPP experiments ATP doses exceeded the dose range stated in the protocols.
- In 2 animals more than 12 PPP experiments were conducted (1 animal with 13 times; 1 animal with 15 times). The 3/13/00 protocol did not contain this, but in the 10/15/01 protocol the maximum number of PPP was added to 12.
- One c-section resulting in a 4th major surgery (the 3/13/00 protocol stated that the maximum number of major surgeries was 3. This confusion occurred because the protocol stated that “the animals used for the project 1 (puberty-project) with PPP experiment can be used for breeding females in project 2, in which 3 c-sections were allowed”.
2. Inadvertent Violations
- Five animals received reheadcap surgeries. This procedure was not described in the 3/13/00 protocol, but it was added in 10/15/01 protocol.
- In 15 animals blood draws were conducted on project 2, in which no blood draw was described. In projects 1 and 4 blood drawings are described.
- In 12 animals more than 4 ml of bloods were drawn in one week. The protocol stated that taking more than 4 ml/week of bloods requires CBC. (See also related problems in No.3).
- Forty-two animals received higher doses (up to 20 mg/kg) of ketamine. The protocol stated that ketamine dose will be 10-15 mg/kg.
- Antibiotics were given to 18 animals after PPP experiments. In most cases a staff veterinarian approved the treatment, but consent was not in writing. In fact, Carol Emerson suggested antibiotics after PPP experiments on a regular basis.
- Prophylactic antibiotics were given before and after surgeries, such as cranial pedestal implantation as well as cranial pedestal repair and removal, in 59 animals. Staff veterinarians knew of this practice, but we failed to describe it in the protocol.
3. Errors due to Reproductive Services for Breeding in Our Animals
- In 7 animals Reproductive Services took blood samples up to 14 ml in a week under our protocol.
- Reproductive Services conducted ultrasounds in 8 animals under our protocol. Ultrasound examination was not described in the protocol.
4. Record Errors
r94070 6/15/01 Remark by a veterinary assistant says "in chair".
However, this animal did not have cranial pedestal at
this time and there is no chairing record. So, there is no
way that she was in chair.
r96130 7/10/00-7/14/00 Record says she was in chair after cranial pedestal
removal. This is not possible.
r96112 8/8/00 The animal should be 96119. Record has been corrected.
r99046 6/12/01 The animal should be 97046. Record has been corrected.
r98003 6/12/01 The animal should be 98033. Record has been corrected.
r98040 7/10/01 The animal should be 98049. Record has been corrected.
r84108 10/3/00 This monkey does not belong to this protocol, because it
is a male. To take blood Reproductive Services assigned to
our protocol.
rhaa56 10/3/00 This monkey does not belong to this protocol, because it
is a male. To take blood Reproductive Services assigned to
our protocol.
r87100 12/8/00 This monkey does not belong to this protocol, because it
is a male. To take blood Reproductive Services assigned
to our protocol.
rhaq36 4/30/01 Cranial pedestal removal surgery was stated as major
surgery.
r93061 3/13/01 Cranial pedestal removal surgery was stated as major
surgery.
rh1935 10/8/01-10/11/01 Chairing is not stated in colony record.
rh2116 05/14/01 Record states "out of chair on 5/14". But it should be 5/4,
because there is no way that she was in chair for 13 days.
rh2118 04/25/01 PPP experiment was conducted on 4/26/01. The date of
the out chair should be 4/26/01.
r93058 12/10/02 PPP experiment was conducted on 12/11/02. The date of
the out of chair should be 12/11/02.
r96082 11/27/00-11/29/00 Chairing is not stated in colony record.
r98033 1/6/03-1/8/03 Chairing is not stated in colony record.
r99031 2/18/02 & 2/19/01 Two records of cannulation. 2/19/01 is correct, based on
chairing record.
r99031 03/12/02 Cannulated three weeks after last time by accident.
However no PPP experiment was conducted.
r99077 09/10/01 Record says that pedestal repair and cannula implantation.
Only cranial pedestal repair surgery was conducted.
r01050 10/14/02 There is no record saying that ketamine was
injected.
rhYO3 05/12/01 Cannulation date should be corrected to 14th, based on
the chairing record and the PPP experiment, which was
conducted on the 17th.
5. Others
- Three animals had skin lesions after chairing.
* * * * * *
All “Apparent Violations” were recognized during the review process for the renewal of recent protocol (approved on 04/14/03) and discussed with the Graduate School IACUC. Also, my letter date 6/5/02 in response the Dr. Eric Sandgren’s letter date 5/13/03 dealt with some of the issues. Thus, they have been resolved.
Most of the “Inadvertent Violations” are due to unrealistic descriptions in the previous protocol or absence of our recognition, e.g., the activity by the Reproductive Services Unit. We will submit an amendment to correct these errors:
1. A series of 3 ml blood draws up to 12 ml in an experiment will be added to project 2 and project 4.
2. Ketamine dose will be changed from 10-15 mg/kg to 10-20 mg/kg.
3. Prophylactic antibiotic treatments before and after surgeries such as cranial pedestal implantation, cranial pedestal repair and removal, will be added to the protocol.
4. Activities of the Reproductive Services Unit, such as blood draw up to 14 ml/week, ultrasound examination and possible artificial insemination, will be added to the protocol.
Examination of clinical records from 2000 – 2003 by Christine Parks and Amanda Crumbaugh.
- Unsual number of death/serious illness in animals used late 2000 – mid 2002 (23 monkeys used; events of use included even if outside above date range.) Some of the animals were aged. The following are summaries/quotes from the clinical records.
- rhap53-Died 6/17/02, 6 days after experiment (push pull perfusion). Necropsy report in clinical record said : “The infarct and thrombus most likely occurred during the experimental procedure 6 days prior to death. They could account for the latered mentation reported clinically, but the ventricular hemorrhage and acute brain swelling are the most probable reason for the monkeys rapid clinical decline and demise.”
- rhao21 – In 2001, animal had problems such as lethargy, inappetence, lying down in cage after experiment, cannula implant infection, holding hand stiffly, ulcers. Was noted to have a guarded prognosis but recovered (3/2001). Used again in late 2001 and January 2002; ulcers on 1/29/2002.
- 95105 – 3/11 cannulated On 03/15/2002 – poor recovery after experiment (vomiting, lethargy, laying down in cage, dehydrated). 5/28/02 cannula placed. 5/31/2002 – “lethargic and not eating post procedure; evolved to apnea; good hr and pulse; no spontaneous respiration; pc02 61.4 mmttg; pupils fixed and dilated; elected euthanasia – by i.b.” Necropsy: Cerebral/cerebellum edema but no histological diagnosis due to accidental freezing of tissue.
- rh2116 – 03/06/2002 – “received emergency (sic) call that chaired animal had died; dead at least 5 minutes (no crt), attempted chest compressions; no heart beat/blood pressure; called pathologist on duty, left message – by [REDACTED]. Three moderate to severe ulcers on caudal thigh, pressure point in chair; blood on ulcers – by [REDACTED] . . .” Blood clot in heart found on necropsy: probably throwing thrombi into circulation. Laboratory notebook noted that something unspecified is “bloody” or “pinkish” while in the chair.
- 00046 – 11/08/2002 “in chair on experiment; ulcer (1cm) noted on left foot; cleaned and applied ointment; some swelling of foot, foot is warm; able to use foot and is eating; plan-observe – by [REDACTED]” “removed from cahir (sic) procedure 11-7 p.m.; left ankle appears irritated with open sore present on lateral surface; appears bright, alert, responsive and hydrated with good attitude; discuss treatment with vet- by j.b.”
- 00040 – 12/20/200 – “post push-pull observation-animal is lethargic” 12/21/200 – “down in cage; eyes open; will move if touched; push-pull procedure ended 12/20; antibiotic started 12/20; plan- collect cbc/chemistry; monitor closely; [REDACTED] ” Lethargic for a few more days but improved by